Description: This report evaluates alternative payment models that potentially could be instituted by healthcare payers and manufacturers.

Description: In the current value-based care marketplace, there are various reimbursement models that tie payments for care delivery to the quality of the care provided. The purpose is clear – change reimbursement to focus on value by rewarding better outcomes and lower spending. However, implementation it is complex, and many challenges emerge during this transition for both providers and payers.Providers often lack sophisticated actuarial capabilities or clear understanding of the connection between finance and clinical operations. For these reasons, they enter risk arrangements without knowing how to strategically manage and mitigate risks and fully transfer the reimbursement changes into clinical decisions. For payers, a truly viable value-based payment model that rewards the most valuable providers needs a multidisciplinary approach and a solid financial model. Such a model also requires transparency and a clear transitional road map for providers to encourage participation and collaboration. In this session, we will discuss lessons learned through case studies of working with both providers and payers on value-based care issues. We will illustrate the current state of the complex financial structures by presenting examples of value-based financial models, feasibility analyses, and strategies to design a payment model beneficial to both providers and payers. We will also explore the clinical collaboration necessary to make it all work, as well as present some best practice strategies to facilitate strong payer-provider collaboration.

Description: US pharmacy prices have entered a new era of growth driven by Specialty medications. A bevy of state and national regulations have been proposed to address pharmacy pricing, industry structure and transparency.Health actuaries will learn about US pharmacy pricing structure and how proposed legislation could affect future costs. Actuaries that have responsibility for pharmacy rate/budget setting, RFPs or trend projection will benefit from a deeper understanding of the US pharmacy market landscape and gain an international perspective.

Description: An edited written interview with two actuaries and a public health professional on issues related to the intersection between the two fields.

Description: This is a case study session where the speakers will describe a project where a major health system converted its provider distinct reimbursement (i.e., separate physician IPA and hospital capitation) to an integrated reimbursement involving global capitation. The session will discuss the strategic issues considered by the parties and how they evaluated them in their decision process. This session will provide attendees an example of how to approach this type of decision.

Description: The presenters will provide insights into fraud and abuse risk in the health insurance industry, including an examination of traditional and predictive modeling techniques for both prevention and detection. Emphasis will be placed on current and emerging risks. Canadian examples and perspectives will be offered, but the applications for attendees to use in practice are non-nation specific.

Description: Yi-Ling Lin, FSA, MAAA, FCA, started the SOA’s Predictive Analytics Certificate Program to keep pace with the impact big data and predictive modeling is having on the health care industry

Description: This short article presents the latest SOA health research report on alternative payment models for high-cost curative therapies.

Description: As value-based solutions evolve, it is more important than ever for providers to understand their performance and how it is measured, along with the drivers of success. Presenters will cover the evolution of past risk-transfer programs such as Medicare Shared Savings Program and Next Generation ACO. They will also discuss the new Primary Care First and Direct Contracting models recently announced by CMS.

Description: The presenters will focus on best practices in drug claim management in North America. The presentation is geared toward Canadian practice and insights, but is useful for practitioners in the U.S. and elsewhere, as well.